I went to a conference recently where I was told in an E/M panel Q&A that a statement after the Discussion portion of the note stating "31 minutes of the 60 minute visit spent in coordination and counseling of care" was not adequate to code on the basis of time, even if the Discussion documented what was talked about. My coworker disagrees, as the information is stated in the Discussion. Guidance?
I was also told during this panel that even if Time is documented correctly, the medical decision making and complexity should determine the correct level, not the documentation itself. Help?
Citations are always appreciated. I have only been coding for 6 months, so your input is valued. Thank you.
I was also told during this panel that even if Time is documented correctly, the medical decision making and complexity should determine the correct level, not the documentation itself. Help?
Citations are always appreciated. I have only been coding for 6 months, so your input is valued. Thank you.